Evidence-Based Design Supports Evidence-Based Medicine in the ICU

Author

D. Kirk Hamilton, B.Arch, MSOD, FAIA, FACHA,

is an Associate Professor
of Architecture and a Fellow of the Center for Health Systems & Design at
Texas A&M University for which he currently serves as Interim Director. His
research area is the relationship of evidencebased health facility design to
measurable organizational performance. He has chaired the ICU Design Committee
of the Society for Critical Care Medicine (SCCM) and currently serves on the
boards of the Center for Health Design (CHD) and the Coalition for Health
Environments Research (CHER). Hamilton is the past president of both the
American College of Healthcare Architects (ACHA) and the AIA Academy of
Architecture for Health.

Peter Pronovost, MD, of Johns Hopkins, lost his father to a
medical error while in medical school and went on to experience the disturbing
preventable loss of a child in his intensive care unit (ICU). Josie King died
of dehydration in one of the world’s premier academic hospitals. This has made
Pronovost a tireless and widely recognized crusader for evidence-based
improvements in critical care (Miller 2002). It is difficult to imagine that
making medical decisions on the basis of the best available credible research
findings would not lead to improved outcomes. This concept has been spreading
since the early nineties.

"Evidence-based medicine is the conscientious, explicit and
judicious use of current best evidence in making decisions about the care of
individual patients." (Sackett et al. 1996)

As an architect specialized in the design of medical environments,
including critical care, I propose that evidence-based design is an obvious
analog to evidence-based medicine. Evidence-based design is the conscientious
and judicious use of current best evidence, and its critical interpretation, to
make significant design decisions for each unique project. These design
decisions should be based on sound hypotheses related to measurable outcomes. I
have previously published a description:

"Evidence-based designers make critical decisions, together
with an informed client, on the basis of the best available information from
credible research and the evaluation of completed projects." (Hamilton
2003)

Healthcare facility designs based on the findings of research are
developed in an attempt to create environments that improve care by enhancing patient
safety and being actively therapeutic, supportive of family involvement,
efficient for staff performance and restorative for workers under stress. There
is a clear compatibility of common themes between the design of healthcare
environments based on research and the practice of evidence-based medicine in
those physical settings.

There is a growing body of credible research relating the care
environment to clinical outcomes. Environmental psychologists Roger Ulrich,
PhD, of Texas A&M University and Craig Zimring, PhD, of the Georgia
Technical Institute, together with their students, were funded by the Center
for Health Design and the Robert Wood Johnson Foundation to produce a
meta-analysis of the credible research in this area (Ulrich et al. 2004). They
found more than 650 rigorous studies that dealt with patient and staff safety
issues, the environment’s impact on stress and the care environment’s
relationship with clinical quality.

An interesting and related example of application in the field
comes to us from the Neuro ICU at Emory University in Atlanta. Dr. Alan Samuels,
the unit director, found himself less than satisfied with proposed plans for a
replacement ICU. He approached Zimring at nearby Georgia Tech to ask whether
there was evidence relating clinical outcomes to design of critical care
environments. They involved graduate students in a study which led to a design
charrette, or intensive design session, with the architects. On the basis of
the evidence collected, the ICU was redesigned. Samuels plans to study outcomes
when the project is completed and report his results. I look forward to their
publication.

More serious research relating critical care environments and
outcomes is needed to answer important questions. In the area of safety, we
need better research on the environment’s role in spreading or preventing the
spread of infection, as well as the efficacy and design of hand hygiene
locations. We need to know which designs are associated with reduced error and
injury. We know that daylight, artificial lighting, temperature, humidity, odor
and noise all have physiological impact on the building’s occupants, but we
need to know much more about how they impact clinical outcomes in the ICU.
Since communication is a major issue in the ICU, we need design research to
discover better ways to encourage and enhance it. If productivity, performance
and alertness are issues for management, then research can help identify
effective ways in which the physical setting can be designed as an enabler of
the work process, rather than a barrier.The range of relevant studies is nearly
infinite.

Clinicians who subscribe to the tenets of evidencebased practice
in critical care should become champions of collaboration with architects and designers
who are also working in an evidencebased model. Both must collaborate with researchers
who can answer key questions for them. They are each, after all, seeking the
same thing. The synergistic results will speak for themselves.

Author<br>
D. Kirk Hamilton, B.Arch, MSOD, FAIA, FACHA,
is an Associate Professor
of Architecture and a Fellow of the Center for Health Systems &amp; D

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